Foot Problems in Diabetes: An Overview

Diabetic foot wound ulcers management by vacuum sealing drainage: A meta-analysis

The meta-analysis aimed to assess and compare diabetic foot wound ulcer management by vacuum sealing drainage. Using dichotomous or contentious random- or fixed-effects models, the outcomes of this meta-analysis were examined, and the odds ratio (OR) and the mean difference (MD) with 95% confidence intervals (CIs) were computed. Twenty-three examinations from 2000 to 2023 were enrolled for the present meta-analysis, including 1928 individuals with diabetic foot ulcers. Vacuum sealing drainage had significantly lower wound healing (OR, 2.35; 95% CI, 1.79-3.08, p < 0.001), lower duration of therapy (MD, -6.19; 95% CI, -10.06 to -2.32, p = 0.002), higher wound size reduction (MD, 4.22; 95% CI, 0.87-7.56, p = 0.01) and lower complication (OR, 0.32; 95% CI, 0.13-0.80, p = 0.01) compared with standard therapy in patients with diabetic foot ulcers. The examined data revealed that vacuum sealing drainage had significantly lower wound healing, duration of therapy and complication rates, as well as higher wound size reduction, compared with standard therapy in patients with diabetic foot ulcers. Yet, attention should be paid to its values since most of the selected examinations had a low sample size.

Efficacy of the Novel Formulation of Topical Liothyronine and Liothyronine-insulin in Mild to Moderate Diabetic Foot Ulcer: A Randomized, Triple-blind Clinical Trial

BACKGROUND

Diabetic foot ulcer (DFU) is one of the challenging complications of chronic diabetes.

OBJECTIVE

The study aimed to investigate whether liothyronine (T3) and liothyronineinsulin (T3/Ins) topical preparations could significantly reduce the healing time of DFU.

METHODS

A prospective, randomized, placebo-controlled, patient-blinded clinical trial was conducted on patients with mild to moderate DFU, over a lesion area of no greater than 100 cm2. The patients were randomized to receive T3, T3/Ins, or honey cream 10% as the routine of care twice a day. Patients were examined for tissue healing weekly for 4 weeks, or until the total lesion clearance was observed, whichever was earlier.

RESULTS

Of 147 patients with DFUs, 78 patients (26 per group) completed the study and were included in the final evaluation. At the time of study termination, all participants in each of the T3 or T3/Ins groups were free of symptoms based on the REEDA score, while about 40% of participants in the control group were detected with each of grades 1, 2, or 3. A significant difference was observed on days 7, 14, and 21 of consumption of topical preparations (p-value < 0.001). The mean time to complete wound closure in the routine care group was about 60.6 days, while it was 15.9 and 16.4 days in T3 and T3/Ins groups, respectively. Within the T3 and T3/Ins groups, significant earlier wound closure was detected at day 28 (p-value < 0.001).

CONCLUSION

T3 or T3/Ins topical preparations are effective for wound healing and acceleration of wound closure in mild to moderate DFUs.

Cold Atmospheric Pressure Plasma: A Growing Paradigm in Diabetic Wound Healing-Mechanism and Clinical Significance

Diabetes is one of the most significant causes of death all over the world. This illness, due to abnormal blood glucose levels, leads to impaired wound healing and, as a result, foot ulcers. These ulcers cannot heal quickly in diabetic patients and may finally result in amputation. In recent years, different research has been conducted to heal diabetic foot ulcers: one of them is using cold atmospheric pressure plasma. Nowadays, cold atmospheric pressure plasma is highly regarded in medicine because of its positive effects and lack of side effects. These conditions have caused plasma to be considered a promising technology in medicine and especially diabetic wound healing because studies show that it can heal chronic wounds that are resistant to standard treatments. The positive effects of plasma are due to different reactive species, UV radiation, and electromagnetic fields. This work reviews ongoing cold atmospheric pressure plasma improvements in diabetic wound healing. It shows that plasma can be a promising tool in treating chronic wounds, including ones resulting from diabetes.

Comparison Between the Efficacy of Spinal Cord Stimulation and of Endovascular Revascularization in the Treatment of Diabetic Foot Ulcers: A Retrospective Observational Study

OBJECTIVE

We aimed to compare the effects of spinal cord stimulation (SCS) with those of endovascular revascularization on the treatment of diabetic foot ulcers.

MATERIALS AND METHODS

A total of 104 patients with diabetic foot ulcers who met the inclusion criteria were retrospectively analyzed and classified to the SCS treatment group (n = 46) and endovascular revascularization treatment group (n = 46). The quality-of-life scores (Quality of Life Scale for Patients with Liver Cancer v2.0), visual pain analog scale score, lower limb skin temperature, lower limb arterial ultrasound results, and lower extremity electromyography results were analyzed to compare the efficacy of the two treatments for diabetic foot ulcers in the two groups before surgery and six months after surgery.

RESULTS

A total of 92 patients (men: 73.9%, mean age: 66.51 ± 11.67 years) completed the six-month postoperative follow-up period. The patients in the SCS treatment group had a higher quality-of-life score (25.54% vs 13.77%, p < 0.05), a larger reduction in pain scores (69.18% vs 37.21%, p < 0.05), and a larger reduction in foot temperature (18.56% vs 7.24%, p < 0.05) than those of the endovascular revascularization treatment group at six months after surgery. The degree of vasodilation in the lower limbs on color Doppler arterial ultrasound and the nerve conduction velocity were higher in the SCS treatment group than in the endovascular revascularization treatment group at six months after surgery (p < 0.05).

CONCLUSION

SCS was more effective than endovascular revascularization in improving quality of life, relieving pain, improving lower limb skin temperature, increasing lower limb blood flow, and improving nerve conduction in patients with diabetic foot ulcers at six months after surgery.

A core/shell nanogenerator achieving pH-responsive nitric oxide release for treatment of infected diabetic wounds

Nitric oxide is critical for eliminating infection and promoting regeneration in diabetic wounds. However, clinical uses of nitric oxide are limited by its high activity and lack of specificity in targeting infections. Herein, we develop an intelligent nitric oxide nanogenerator comprising isosorbide dinitrate (ISDN)-coated copper sulfide (CuS)/calcium carbonate (CaCO₃) core/shell nanoparticles (CuS@CaCO₃-ISDN) to target the acidic microenvironment of the infected diabetic wounds. Meaningfully, triggered by acid decomposition of CaCO₃, this nanogenerator can achieve a responsive and accelerated release of nitric oxide from ISDN through enzyme-mimicking redox processes that involve CuS nanoparticles and then inactivate biofilm bacteria through the pathways of oxidative stress and disruption of adenosine triphosphate (ATP)-related energy metabolism. Moreover, after eliminating the infection, the pH-responsive release of nitric oxide can promote the proliferation of blood vessels and tissue regeneration and accelerate diabetic wound closure. This study expands the use of nitric oxide donors in wound treatment by developing the enzyme-mimicking release strategy, and the pH-responsive core/shell nanogenerator is promising for a variety of anti-infection therapeutic applications.

Oxygen-Releasing Composites: A Promising Approach in the Management of Diabetic Foot Ulcers

In diabetes, lower extremity amputation (LEA) is an irreversible diabetic-related complication that easily occurs in patients with diabetic foot ulcers (DFUs). Because DFUs are a clinical outcome of different causes including peripheral hypoxia and diabetic foot infection (DFI), conventional wound dressing materials are often insufficient for supporting the normal wound healing potential in the ulcers. Advanced wound dressing development has recently focused on natural or biocompatible scaffolds or incorporating bioactive molecules. This review directs attention to the potential of oxygenation of diabetic wounds and highlights current fabrication techniques for oxygen-releasing composites and their medical applications. Based on different oxygen-releasable compounds such as liquid peroxides and solid peroxides, for example, a variety of oxygen-releasing composites have been fabricated and evaluated for medical applications. This review provides the challenges and limitations of utilizing current oxygen releasable compounds and provides perspectives on advancing oxygen releasing composites for diabetic-related wounds associated with DFUs.

The evaluation of efficacy of atmospheric pressure plasma in diabetic ulcers healing: A randomized clinical trial

The aim of this study is to evaluate the efficacy and safety of cold atmospheric plasma (CAP) as a novel therapy for diabetic foot ulcers. This was an investigator-blinded, randomized controlled trial of 14 weeks (6 weeks of treatment and 8 weeks of follow-up). Twenty patients with diabetic foot ulcers were divided into two groups: the control group receiving standard wound care and the plasma group, which received CAP twice a week for six consecutive weeks in addition to standard wound care. The ulcer size, amount of exudate, and wound grading were determined weekly. Cold plasma was produced by applying a high voltage (4.5 kV) and a high frequency (22 kHz) to helium gas. Exudate from wounds treated with CAP showed a significant reduction in the third week after complete treatment (p = 0.039). The wound grading of the ulcers improved by the sixth week (p = 0.019), and the sizes of ulcers significantly decreased in the plasma group at the end of the treatment period (p = 0.007). In this randomized clinical trial, CAP was an effective treatment option for diabetic foot ulcers in terms of wound surface reduction and antibacterial effects.

Comparison of Vacuum Sealing Drainage and Traditional Therapy for Treatment of Diabetic Foot Ulcers: A Meta-Analysis

Vacuum sealing drainage (VSD) is a noninvasive adjunctive therapy to help patients with diabetic foot ulcers by reducing edema and promoting wound healing and formation of granulation tissue. Multiple databases were searched for relevant studies, and full-text articles comparing VSD and conventional therapy were reviewed. Meta-analyses were conducted with Review Manager 5.0 software to estimate the results of the selected articles. Forest plots, sensitivity analysis, and bias analysis were also performed on the included articles. In total, 10 studies satisfied the inclusion criteria and were selected in this study. The meta-analysis suggested that the duration of therapy, decrease of wound size, and efficacy rate showed statistically significant differences between the 2 groups (mean difference = -12.86; 95% confidence interval [CI] -12.86 to -8.52; p < .00001; mean difference = 8.71; 95% CI 3.25 to 14.17; p = .002; relative risk = 1.41; 95% CI 1.22 to 1.62; p < .00001, respectively) although the complication rate between the 2 groups was comparable (relative risk = 0.83; 95% CI 0.60 to 1.16; p = .28). Publication bias was not assessed because only a few articles were included. In conclusion, VSD is a more effective therapy and is associated with a greater decrease in wound size and shorter time to wound healing, compared to the conventional method.

A Clinical Review of Diabetic Foot Infections

"Diabetic foot infections (DFIs) are a common cause of morbidity and mortality. This article summarizes current knowledge regarding DFI epidemiology, disease pathogenesis, and the impact of antimicrobial resistance among DFI. An evidence-based approach to clinical assessment, diagnosing osteomyelitis, as well as medical and surgical treatment is discussed, including a review of empiric and directed antibiotic treatment recommendations. The current state and needs of the clinical literature are identified throughout, with a discussion of the supporting role of infectious diseases specialists as well as future directions of the field."

GnRH impairs diabetic wound healing through enhanced NETosis

It has been reported that neutrophil extracellular traps (NETs) impair wound healing in diabetes and that inhibiting NET generation (NETosis) improves wound healing in diabetic mice. Gonadotropin-releasing hormone (GnRH) agonists are associated with a greater risk of diabetes. However, the role of GnRH in diabetic wound healing is unclear. We determined whether GnRH-promoted NETosis and induced more severe and delayed diabetic wound healing. A mouse model of diabetes was established using five injections with streptozotocin. Mice with blood glucose levels >250 mg/dL were then used in the experiments. GnRH agonist treatment induced delayed wound healing and increased NETosis at the skin wounds of diabetic mice. In contrast, GnRH antagonist treatment inhibited GnRH agonist-induced delayed wound healing. The expression of NETosis markers PAD4 and citrullinated histone H3 were increased in the GnRH-treated diabetic skin wounds in diabetic mice and patients. In vitro experiments also showed that neutrophils expressed a GnRH receptor and that GnRH agonist treatment increased NETosis markers and promoted phorbol myristate acetate (PMA)-induced NETosis in mouse and human neutrophils. Furthermore, GnRH antagonist treatment suppressed the expression of NETosis markers and PMA-induced NETosis, which were increased by GnRH treatment. These results indicated that GnRH-promoted NETosis and that increased NETosis induced delayed wound healing in diabetic skin wounds. Thus, inhibition of GnRH might be a novel treatment of diabetic foot ulcers.

Retrospective analysis of diabetic foot osteomyelitis management and outcome at a tertiary care hospital in the UK

Objectives

This study aimed to analyse retrospectively management and outcomes of the diabetic foot osteomyelitis (DFOM) multi-disciplinary team at St Thomas’ Hospital, London.

Methods

Patients admitted during 2015 with diagnosis of DFOM were included. Data were obtained from medical and microbiology records.

Results

275 patients were admitted for DF infection in 2015: 45.1% had OM (75% males). 40% were newly diagnosed with DF ulcer (DFU). 81% patients had X-ray and 28% had MRI. Bone infection was confirmed by MC&S in 53% cases. 930 microbiological isolates were obtained: 63% were Gram-positive microorganisms [S.aureus and MRSA (~40%), CoNS (20%), and E.faecalis (8%)]. All MRSA were vancomycin and linezolid sensitive. 23.2% isolates were vancomycin-resistant enterococci. 24% isolates were Gram-negative organisms: P.aeruginosa (42%), E.coli (13%), and E.cloacae (12%). Meropenem resistance was low; 5.4% P.aeruginosa, 87.5% A.baumanii. 76% patients received co-amoxiclav; 41% received ≥3 antibiotics; 17% received >3 months antibiotics. Hospital mean-length of stay was 26.1 days. Ulcer time-to-heal was >6 months in 25% patients. 22% ulcers healed without surgery, 60% healed after minor amputation, 12% patients had major amputation.

Conclusion

Despite current MDT approach, many patients progress to amputation. DF-OM still represents a challenging clinical condition, requiring further study to develop better management guidelines.

Clinical, Etiological, Anatomical, and Bacteriological Study of "Diabetic Foot" Patients: Results of a Single Center Study

Objective: To examine the clinical pattern of foot-related complications in type 2 diabetes patients.

Material and methods: A cross-sectional study was conducted among indoor, adult type 2 diabetes patients with risk factors for diabetic foot complications. The diabetic neuropathy symptom score (DNSS), Doppler scanning, ankle brachial pressure index (ABPI) assessment, neuropathy assessment, neuropathic disability score (NDS), biothesiometry evaluation, and bacteriological examination was performed. Diabetic foot risk stratification was done using the NICE risk stratification system. Foot ulcer severity was assessed with the Lipsky severity grading system.

Results: Ninety-one patients (mean age 59 years; male 65.9%) were included, of which 20 (22%) had a history of ulcer and 40 (44%) were smokers. Seventy-seven (83.5%) patients had a neuropathy symptom score between 4 and 9. Biothesiometry vibration perception threshold (VPT) was “severe” in 55 (60.4%) patients. Doppler assessment showed triphasic flow in 53 patients (58.2%). Out of 52 patients (57.1%) with neuropathy, 30 (57.7%) had a severe problem. Diabetic foot ulcer, cellulitis, and callus were present in 44 (48.3%), 29 (31.5%), and 11 (12.4%) patients, respectively. Foot ulcers were present on 21 (38%) metatarsal heads, 11 (20%) toes, 10 (18%) heels, 08 (15%) ankles, and 05 (09%) lateral foot borders. Of the 55 patients who underwent culture examination, 30 (33.3%) showed the presence of Staphylococcus aureus. As per NICE risk stratification, 55 patients (60%) were at “very high risk.”

Conclusion: A foot ulcer is the commonest complication in diabetic patients followed by cellulitis. Standardized simple noninvasive testing methods should be used to identify patients at risk for the diabetic foot. Multidisciplinary diabetic foot care could be useful to prevent diabetes-related amputation of the lower extremities.

Platelet rich plasma and growth factors cocktails for diabetic foot ulcers treatment: State of art developments and future prospects

Current advances in diabetic foot ulcers (DFU) treatment are discussed. Normal and pathological wound healing process are observed and the role of growth factors (GFs) is elucidated. Current techniques involving GFs and platelet rich plasma (PRP) are compared. Up-to-date research suggests that treatment with single growth factor (GF) could be insufficient and not encompassing all pathological changes in DFU bed. Efficiency of PRP is rather controversial and lacks evidence. Thus the use of cocktail of particular GFs is suggested. Pro et contra of each approach are discussed.

MDI 301, a synthetic retinoid, depressed levels of matrix metalloproteinases and oxidative stress in diabetic dermal fibroblasts

Diabetic foot ulcerations could result in serious consequences such as amputations. The up-regulation of matrix metalloproteinases and down-regulation of TIMP1 were remarked as distinctive biological characteristics in the diabetic dermal fibroblast. The current study was performed in order to clarify the effect of high glucose on formation of diabetic dermal fibroblast cell. In addition, the effect of MDI 301 on ameliorating diabetic fibroblasts was investigated in this study. The mRNA and protein expression levels of MMPs, TIMP1 and catalase were evaluated against fibroblasts treated with high glucose (30 mM) using qRT-PCR, western blotting and zymography assays. Methods were also employed for investigating the biological effects of MDI 301 on high glucose-induced diabetic fibroblasts. In this study, we found that the unbalance of oxidative stress induced by high glucose concentration play an important role in the formation of diabetic dermal fibroblast from normal cells. In addition, MDI 301, a picolinic acid-substituted ester of 9-cis retinoic acid was employed in this study in order to ameliorate symptoms on diabetic dermal fibroblast induced by high glucose concentration. We found MDI 301 alleviate the effects of high glucose-induced skin damage by balancing the oxidative stress and regulating the MMPs and TIMP1 levels. Our finding indicated that MDI 301 offers the potential for repairing the faulty skin function arising from diabetes.

Nurses' knowledge on diabetic foot ulcer disease and their attitudes towards patients affected: A cross-sectional institution-based study

AIMS AND OBJECTIVES

To assess nurses' knowledge on diabetic ulcer disease and their attitudes towards patients suffering from it and to identify factors which influence them.

BACKGROUND

Diabetic wound care is an evolving specialty with the rising prevalence of diabetes foot complications. As nurses play a key role in wound care, their knowledge and attitudes are important in providing optimum care to patients.

DESIGN

Descriptive cross-sectional survey design.

METHODS

The study was conducted in three teaching hospitals. Data were collected using a pretested, validated, self-administered questionnaire from purposively recruited, voluntarily participating nurses (n = 200) who were in diabetic wound care practice for ≥1 year.

RESULTS

Lack of formal wound care training was reported by 91.2%. Mean knowledge score was 77.9 (range 53.3-100 on a scale from 0-100) with 57.8% of nurses obtaining ≥80%. Nurses demonstrated an overall positive attitude towards caring for diabetic ulcer patients (median = 41, range 23-50 on a scale from 10-50). However, the study identified deficits in core knowledge and some negative attitudes such as insensitivity to pain. Statistically significant associations were seen between nurses' knowledge and duration of nursing, wound care experience and the type of unit they are attached to. In-service education (77.2%) and knowledge sharing with peers (77.9%) were the most popular knowledge-updating sources. Although 98.6% of nurses were interested in wound care, only 8.3% wished to engage in research. No correlation was observed between nurses' knowledge and attitudes.

CONCLUSION

Gaps in core knowledge and negative attitudes may be attributed to inadequate training, suboptimal update of knowledge and lack of interest in wound care research.

RELEVANCE TO CLINICAL PRACTICE

Wound care training should be made mandatory to improve quality of care given by nurses to patients with diabetic ulcers. Continuous professional development, evidence-based practices and wound care research should be encouraged.

Risk factors of diabetic foot Charcot arthropathy: a case-control study at a Malaysian tertiary care centre

INTRODUCTION

This study aimed to determine the risk factors of diabetic Charcot arthropathy of the foot among diabetic patients with and without foot problems.

METHODS

This was a case-control study involving diabetic patients attending the Diabetic Foot Care and Wound Management Clinic at University Malaya Medical Centre, Kuala Lumpur, Malaysia, from June 2010 to June 2011. Data on sociodemographic profiles, foot factors and diabetes characteristics was collected and analysed.

RESULTS

A total of 48 diabetic patients with Charcot arthropathy of the foot were identified. Data from these 48 patients was compared with those of 52 diabetic patients without foot problems. Up to 83.3% of patients with diabetic Charcot arthropathy presented with unilateral Charcot foot, most commonly located at the midfoot (45.8%). Patients with a history of foot problems, including foot ulcer, amputation, surgery or a combination of problems, had the highest (26-time) likelihood of developing Charcot arthropathy (odds ratio 26.4; 95% confidence interval 6.4-109.6). Other significant risk factors included age below 60 years, more than ten years' duration of diabetes mellitus and the presence of nephropathy.

CONCLUSION

A history of prior diabetic foot problems is the greatest risk factor for developing diabetic Charcot arthropathy, compared with other risk factors such as diabetes characteristics and sociodemographic profiles. Preventive management of diabetic foot problems in the primary care setting and multidisciplinary care are of paramount importance, especially among chronic diabetic patients.

Development of a Plantar Load Estimation Algorithm for Evaluation of Forefoot Load of Diabetic Patients during Daily Walks Using a Foot Motion Sensor

Forefoot load (FL) contributes to callus formation, which is one of the pathways to diabetic foot ulcers (DFU). In this study, we hypothesized that excessive FL, which cannot be detected by plantar load measurements within laboratory settings, occurs in daily walks. To demonstrate this, we created a FL estimation algorithm using foot motion data. Acceleration and angular velocity data were obtained from a motion sensor attached to each shoe of the subjects. The accuracy of the estimated FL was validated by correlation with the FL measured by force sensors on the metatarsal heads, which was assessed using the Pearson correlation coefficient. The mean of correlation coefficients of all the subjects was 0.63 at a level corridor, while it showed an intersubject difference at a slope and stairs. We conducted daily walk measurements in two diabetic patients, and additionally, we verified the safety of daily walk measurement using a wearable motion sensor attached to each shoe. We found that excessive FL occurred during their daily walks for approximately three hours in total, when any adverse event was not observed. This study indicated that FL evaluation method using wearable motion sensors was one of the promising ways to prevent DFUs.

Differences in the mechanical characteristics of plantar soft tissue between ulcerated and non-ulcerated foot

AIMS

The purpose of this study was to investigate the differences in mechanical properties of the plantar soft tissue between the ulcerated and non-ulcerated feet in patients with diabetic neuropathy.

METHODS

Thirty nine patients who met the inclusion criteria participated in this study. Ten out of 39 participants had an active ulcer at a site other than the plantar heel and the first metatarsal head. Real time ultrasound elastography was performed to measure the soft tissue thickness and stiffness of the heel pad and sub-metatarsal fat pad. To account for the qualitative nature of conventional real time elastography, relative tissue stiffness was assessed against that of a standardised ultrasound standoff material.

RESULTS

The results indicated that the ulcerated group had a significantly lower heel pad relative stiffness (t (37)=2.559, P=0.015, η2=0.150) in the left foot.

CONCLUSIONS

The observed difference in the stiffness of the heel pad between the ulcerated and non-ulcerated feet indicates a possible link between tissue mechanics and ulceration. Further analysis of the data proposed in this study provided a quantitative assessment of plantar fat pad deformability which can contribute to understanding the role of tissue biomechanics in ulceration.

Sociodemographic and clinical characteristics of patients with diabetic foot ulcer

Summary Introduction: Diabetic foot is one of the most serious complications of diabetes affecting about 15% of all diabetes patients, and it is the leading cause of nontraumatic lower limb amputations. This study presents a sociodemographic and clinical characterization of patients with diabetic foot ulcer indicated for amputation surgery. Methods: A cross-sectional study with 206 patients with type 2 diabetes and a diabetic foot ulcer indicated for amputation surgery. Patients were assessed on sociodemographic and clinical characteristics, pain intensity and pain interference, after answering the Brief Pain Inventory, and on pain descriptors according to the Douleur Neuropathique 4. Results: Most patients were male, with little formal education and a mean age of 66 years. They had been diagnosed with type 2 diabetes for 18 years on average, and with diabetic foot ulcer on average 4 years prior to the assessment. About 59% of patients experienced pain in the lower limb that significantly affect all areas of their functioning. Conclusion: The social demographic variables play an important role in diabetic foot ulceration. Given that the neuropathic ulcers are more easily preventable, systematic monitoring of patients with neuropathy is important. In patients with neuroischemic foot, strategies to cope or manage more efficiently the pain are paramount. Intervention should be multidisciplinary and take into account sociodemographic and clinical factors, as well as the presence, intensity and interference of pain in the patient's daily life activities and whether the patient has family or caregiver support.

Investigation on the effects of the atmospheric pressure plasma on wound healing in diabetic rats

It is estimated that 15 percent of individuals with diabetes mellitus suffer from diabetic ulcers worldwide. The aim of this study is to present a non-thermal atmospheric plasma treatment as a novel therapy for diabetic wounds. The plasma consists of ionized helium gas that is produced by a high-voltage (8 kV) and high-frequency (6 kHz) power supply. Diabetes was induced in rats via an intravascular injection of streptozotocin. The plasma was then introduced to artificial xerograph wounds in the rats for 10 minutes. Immunohistochemistry assays was performed to determine the level of transforming growth factor (TGF-β1) cytokine. The results showed a low healing rate in the diabetic wounds compared with the wound-healing rate in non-diabetic animals (P < 0.05). Moreover, the results noted that plasma enhanced the wound-healing rate in the non-diabetic rats (P < 0.05), and significant wound contraction occurred after the plasma treatment compared with untreated diabetic wounds (P < 0.05). Histological analyses revealed the formation of an epidermis layer, neovascularization and cell proliferation. The plasma treatment also resulted in the release of TGF-β1 cytokine from cells in the tissue medium. The findings of this study demonstrate the effect of plasma treatment for wound healing in diabetic rats.

Clinical and Microbiological Efficacy of Colistin Therapy Alone or in Combination as Treatment for Multidrug ResistantPseudomonas aeruginosaDiabetic Foot Infections with or Without Osteomyelitis

We retrospectively evaluated the safety and effectiveness of colistin alone or in combination with other antimicrobials in eight diabetic patients with severe diabetic foot infections due to multidrug resistant (MDR) Pseudomonas aeruginosa, complicated in 4 cases by osteomyelitis. All patients received colistin after other ineffective antimicrobial treatment, when MDR P. aeruginosa strains were isolated by cultural examination and together with a multidisciplinary care approach including revascularization, surgical debridement and adequate offloading. The mean duration of therapy was 72 +/- 52.9 days. Six out of 8 patients (75%) successfully benefited from colistin therapy, while 2 patients failed and/or experienced side effects that led to discontinuation of therapy. Serious adverse events (i.e. acute renal failure and pulmonary edema) were observed in 1 patient. Our data allow us to conclude that colistin, alone or in combination with other antimicrobials, is safe and effective when administered as part of a multidisciplinary approach, to promote healing of diabetic foot infection due to MDR P. aeruginosa.

Determination of tissue penetration and pharmacokinetics of linezolid in patients with diabetic foot infections using in vivo microdialysis

Staphylococcus aureus and other Gram-positive organisms, including methicillin-resistant S. aureus, continue to be the predominant pathogens associated with diabetic foot infections. Consequently, linezolid is often used to treat these infections. The purpose of the current study was to describe the pharmacokinetic profile and determine the level of penetration of linezolid into healthy thigh tissue and infected wound tissue of the same extremity in 9 diabetic patients with chronic lower limb infections by use of in vivo microdialysis. Hourly plasma and dialysate samples were obtained over a 12-h dosing interval following 3 to 4 doses of linezolid (600 mg intravenously every 12 h). Plasma protein binding was also assessed at 1, 6, and 12 h postdose. The means ± standard deviations (SD) for the maximum concentration in serum (C(max)), the volume of distribution at terminal phase (V(z)), and the half-life (t(1/2)) for linezolid in plasma were 11.99 ± 3.67 μg/ml, 0.71 ± 0.25 liters/kg of body weight, and 4.71 ± 1.23 h, respectively. Mean protein binding was 14.78% (range, 3.85 to 32.03%). The mean areas under the concentration-time curves from 0 to 12 h for the free, unbound fraction of linezolid (fAUC(0-12) values) ± SD for plasma, wound tissue, and thigh tissue were 51.24 ± 12.72, 82.76 ± 59.01, and 92.52 ± 60.44 μg · h/ml, respectively. Tissue penetration ratios (tissue fAUC to plasma fAUC) were similar for thigh (1.42; range, 1.08 to 2.23) and wound (1.27; range, 0.86 to 2.26) tissues (P = 0.648). With the currently approved dosing regimen, linezolid penetrated well into both healthy thigh tissue and infected wound tissue in these diabetic patients.

New insights in diabetic foot infection

Foot ulcers are common in diabetic patients, have a cumulative lifetime incidence rate as high as 25% and frequently become infected. The spread of infection to soft tissue and bone is a major causal factor for lower-limb amputation. For this reason, early diagnosis and appropriate treatment are essential, including treatment which is both local (of the foot) and systemic (metabolic), and this requires coordination by a multidisciplinary team. Optimal treatment also often involves extensive surgical debridement and management of the wound base, effective antibiotic therapy, consideration for revascularization and correction of metabolic abnormalities such as hyperglycemia. This article focuses on diagnosis and management of diabetic foot infections in the light of recently published data in order to help clinicians in identification, assessment and antibiotic therapy of diabetic foot infections.

The compressive mechanical properties of diabetic and non-diabetic plantar soft tissue

Diabetic subjects are at an increased risk of developing plantar ulcers. Knowledge of the physiologic compressive properties of the plantar soft tissue is critical to understanding the possible mechanisms of ulcer formation and improving treatment options. The purpose of this study was to determine the compressive mechanical properties of the plantar soft tissue in both diabetic and non-diabetic specimens from six relevant locations beneath the foot, namely the hallux (big toe), first, third, and fifth metatarsal heads, lateral midfoot, and calcaneus (heel). Cylindrical specimens (1.905 cm diameter) from these locations were excised and separated from the skin and bone from 4 diabetic and 4 non-diabetic age-matched, elderly, fresh-frozen cadaveric feet. Specimens were then subjected to biomechanically realistic strains of approximately 50% in compression using triangle wave tests conducted at five frequencies ranging from 1 to 10 Hz to determine tissue modulus, energy loss, and strain rate dependence. Diabetic vs. non-diabetic results across all specimens, locations, and testing frequencies demonstrated altered mechanical properties with significantly increased modulus (1146.7 vs. 593.0 kPa) but no change in energy loss (68.5 vs. 67.9%). All tissue demonstrated strain rate dependence and tissue beneath the calcaneus was found to have decreased modulus and energy loss compared to other areas. The results of this study could be used to generate material properties for all areas of the plantar soft tissue in diabetic or non-diabetic feet, with implications for foot computational modeling efforts and potentially for pressure alleviating footwear that could reduce plantar ulcer incidence.

Association of the functional A118G polymorphism of OPRM1 in diabetic patients with foot ulcer pain

BACKGROUND

Diabetic foot ulcer (DFU) patients may experience moderate or severe pain. A single-nucleotide polymorphism, at nucleotide 118 for opioid receptor mu 1 (OPRM1), has been reported to alter the opioid effects to relieve acute or chronic pain. The purpose of this study was to elucidate the correlation between nucleotide 118 variants and foot ulcer pain in DFU patients.

METHODS

Sixty-five DFU patients with Grade 2-5 Wagner-Meggitt classification were enrolled. The occurrence of pain in activities was categorized into five grades. Patients were allocated either into the painless DFU group, with a visual analog scale (VAS) pain score <or=3, or into the painful DFU group, with a VAS pain score >or=4 and Grades 3-5 of occurrence of pain in daily activities. DNA was extracted from blood samples of analyzed patients. Using the polymerase chain reaction-single-strand conformation polymorphism analysis and DNA sequencing of nucleotide 118, we identified the genotype distribution and allelic frequencies in DFU patients. The sequences of the forward and the reverse primer are designed as follows: 5'-TAATACGACTCACTATAGGG-3' and 5'-ACGCACACGATGGAGTAGAG-3', respectively.

RESULTS

Fifteen patients were classified into the painful DFU group and 50 patients were classified into the painless DFU group. The amplified DNA fragments showed 26 homozygous (AA), 34 heterozygous (AG), and 5 mutant homozygous (GG) genotypes, with overall A and G allelic frequencies of 66.2% and 33.8%, respectively. The painful DFU group included 10 AA subjects, 4 AG subjects, and 1 GG subject, while the painless DFU group had 16 AA, 30 AG, and 4 GG subjects (P=.038).

CONCLUSION

The A118G polymorphism of mu-opioid receptor may be closely associated with DFU pain in 34 out of 50 patients in the painless group and in 5 out of 15 patients in the painful group. This indicates that the nucleotide 118 variant patients may suffer less DFU pain.

Fatores preditivos da marcha em pacientes diabéticos neuropático e não neuropáticos

OBJETIVO: Analisar a amplitude de movimento do tornozelo e as forças de reação vertical do solo envolvidas na marcha de pacientes portadores de diabetes com e sem neuropatia periférica. CASUÍSTICA E MÉTODO: 36 indivíduos divididos em três grupos: Controle - GC: 10 indivíduos sem diabetes, Diabetes - GD: 10 indivíduos portadores de diabetes sem neuropatia periférica e Neuropatia - GDN: 16 indivíduos portadores de diabetes e neuropatia diabética periférica. Foi realizada análise da marcha - AMTI® OR6/6, e da amplitude de movimento articular tíbio-társica - Sistema Vicom 640® - de todos os participantes. RESULTADOS: O primeiro e segundo pico de força vertical de reação do solo são maiores no grupo Neuropatia e a amplitude de movimento articular do tornozelo é menor nos grupos Diabetes e Neuropatia. CONCLUSÃO: A amplitude de movimento da articulação tíbio-társica está diminuida nos diabetéticos, independente da presença ou ausência de neuropatia periférica, e os diabéticos com neuropatia periférica, apresentaram aumento no primeiro e no segundo pico da força de reação vertical do solo durante a marcha.

Chronic diabetic ulcers under the first metatarsal head treated by staged tendon balancing

We studied a cohort of 26 diabetic patients with chronic ulceration under the first metatarsal head treated by a modified Jones extensor hallucis longus and a flexor hallucis longus transfer. If the first metatarsal was still plantar flexed following these two transfers, a peroneus longus to the peroneus brevis tendon transfer was also performed. Finally, if ankle dorsiflexion was < 5° with the knee extended, a Strayer-type gastrocnemius recession was performed.

The mean duration of chronic ulceration despite a minimum of six months’ conservative care was 16.2 months (6 to 31). A total of 23 of the 26 patients were available for follow-up at a mean of 39.6 months (12 to 61) after surgery. All except one achieved complete ulcer healing at a mean of 4.4 weeks (2 to 8) after surgery, and there was no recurrence of ulceration under the first metatarsal.

We believe that tendon balancing using modified Jones extensor hallucis longus and flexor hallucis longus transfers, associated in selected cases with a peroneus longus to brevis transfer and/or Strayer procedure, can promote rapid and sustained healing of chronic diabetic ulcers under the first metatarsal head.

Foot problems and effectiveness of foot care education in children and adolescents with diabetes mellitus

OBJECTIVES

To assess foot care in paediatric and adolescent patients with diabetes mellitus and to evaluate the effectiveness of foot care education given to participants.

RESEARCH DESIGN AND METHODS

An 8-month prospective study of foot care in children and adolescents with type 1 and type 2 diabetes mellitus who attended diabetes clinics at the Royal Children's Hospital, Melbourne, where foot examination was performed at baseline and at follow-up. Patients and parents were given oral and written advice regarding foot care.

RESULTS

Five hundred and fifty-seven patients were examined at baseline, and 312 patients were reviewed at follow-up 3-6 months later. The majority of foot problems found at first assessment were potentially modifiable disorders of skin and nails (68.8%). The remainder (31.2%) were structural musculoskeletal disorders requiring referral to a podiatrist/orthotist. A total of 532 foot problems were recorded at baseline in a cohort of 557 patients and 161 foot problems at follow-up of 312 patients. Significant reduction of modifiable foot problems was seen at follow-up, particularly in those with longer duration of diabetes and in those whose body mass index was higher.

CONCLUSIONS

This study highlights the importance of foot examination and foot care advice for children and adolescents with diabetes. Larger prospective studies are required to establish prevalence and to optimize preventive interventions.

[Physiopathology of the diabetic foot]

Diabetic foot ulcerations result from different physiopathological mechanisms; a clear understanding of them is crucial to reduce their incidence, provide early care, and finally delay the amputation risk. The three main diabetes complications involved in foot ulcerations are neuropathy, peripheral arterial disease, and infection. The most common pathway to ulceration is peripheral sensorimotor and autonomic neuropathy, leading to loss of sensitivity, foot deformities, high foot pressure, and dry skin. Peripheral arterial disease is more frequent and more serious in the diabetic population. It delays cicatrization and causes gangrene and finally amputation. Infection is also a major complication of ulceration because of its risk of spreading into deep tissue and bone, which increases the risk of amputation. Infection may also generalize and become life-threatening. These complications preferentially affect the foot because it is exposed to hyper pressure, neuropathy, and peripheral arterial disease, which cause distal lesions, and the foot is exposed to a closed atmosphere, a source of soaking and skin frailty. Diabetes itself may enhance the risk of complications stemming from the disease's long-term progression and poor glucose control, thereby affecting ocular and renal functions. Finally, some psychosocial situations such as depression syndrome or poor hygiene possibly enhance diabetic foot occurrence.

Clinical outcome of diabetic foot ulcers treated with negative pressure wound therapy and the transition from acute care to home care

Diabetic foot ulcers affect millions of people in the United States of America and impose tremendous medical, psychosocial and financial loss or burden. Negative pressure wound therapy (NPWT) is generally well tolerated and appears to stimulate a robust granulation tissue response compared with other wound healing modalities. This device may be a cost-effective adjunctive wound healing therapy. This literature review will focus on the clinical outcome of diabetic foot ulcers treated with NPWT, its implication in the transition from acute care to home care, factors that might influence clinical outcomes in home care as well as quality-of-life aspects in these patients. Patient care for diabetic foot ulceration is complex and necessitates multiprofessional collaboration to provide comprehensive wound care. It is clear that when we strive for limb preservation in this most high-risk population, it is important to have an available versatile, efficacious wound healing modality. There is a need for an easy transition from acute care to home care. Resources need to be combined in a collaborative and synergistic fashion to allow patient to perform many daily living activities while receiving the potential benefits of an advanced wound healing modality.

Prevalence and risk factors for neuropathy in a Canadian First Nation community

OBJECTIVE

The purpose of this study was to determine the prevalence of and risk factors for diabetic neuropathy in a Canadian First Nation population.

RESEARCH DESIGN AND METHODS

This was a community-based screening study of 483 adults. Measures included glucose, A1C, cholesterol, triglycerides, homocysteine, hypertension, waist circumference, height, weight, and foot examinations. Neuropathy was defined as loss of protective sensation determined through application of a 10-g monofilament.

RESULTS

Twenty-two percent of participants had a previous diagnosis of diabetes, and 14% had new diabetes or impaired fasting glucose (IFG). The prevalence of neuropathy increased by glucose level: 5% among those with normal glucose levels, 8% among those with new IFG and diabetes, and 15% among those with established diabetes (P < 0.01). Those with neuropathy were more likely to have foot deformities (P < 0.01) and callus (P < 0.001) than those without neuropathy. Among those with dysglycemia (>or=6.1 mmol/l), the mean number of foot problems for those with insensate feet was 3 compared with 0.3 among those with sensation (P < 0.001). In multivariate logistic regression female sex, low education, A1C, smoking, and homocysteine were independently associated with neuropathy, after controls for age.

CONCLUSIONS

Neuropathy prevalence is high, given the young age of our participants (mean 40 years) and was present among those with undiagnosed diabetes. The high number and type of foot problems places this population at increased risk for ulceration; the low level of foot care in the community increases the risk. Homocysteine is a risk factor that may be related to lifestyle and requires further investigation.

Delphi process yielded consensus on terminology and research agenda for therapeutic footwear for neuropathic foot

OBJECTIVE

To investigate areas of consensus and disagreement among Dutch physiatrists concerning prescription of therapeutic footwear for the neuropathic foot and to develop a research agenda.

STUDY DESIGN AND SETTING

Forty participants were physiatrists and experts in the field of orthopedic shoe techniques. Four postal Delphi rounds were followed by a final plenary session.

RESULTS

Forty of the 44 invited experts participated in all postal Delphi rounds, with an overall response of 100%. They achieved consensus on the following. 1. (Dutch) Terminology for two sets of domains and dimensions for the various features of the neuropathic foot and for the shoe characteristics. 2. Application of specific shoe components: insole, shaft, outsole, tongue, and heel. In most features of the neuropathic foot, shaft and outsole domains were linked in the flexibility dimension. 3. Shoe prescriptions for various features of the neuropathic foot in at least four technical domains. Experts disagreed on application of rocker bar and shaft height. In a final conference, 31 experts agreed on a prioritized research agenda.

CONCLUSION

An intensive Delphi process yielded consensus on terminology, and determined areas of consensus and disagreement for future research for the various features of the neuropathic foot and the shoe characteristics.

Compressed air massage hastens healing of the diabetic foot

BACKGROUND

The management of diabetic foot ulcers remains a problem. A treatment modality that uses compressed air massage has been developed as a supplement to standard surgical and medical treatment. Compressed air massage is thought to improve local tissue oxygenation around ulcers. The aim of this study was to determine whether the addition of compressed air massage influences the rate of healing of diabetic ulcers.

METHODS

Sixty consecutive patients with diabetes, admitted to one hospital for urgent surgical management of diabetic foot ulcers, were randomized into two groups. Both groups received standard medical and surgical management of their diabetes and ulcer. In addition, one group received 15-20 min of compressed air massage, at 1 bar pressure, daily, for 5 days a week, to the foot and the tissue around the ulcer. Healing time was calculated as the time from admission to the time of re-epithelialization.

RESULTS

Fifty-seven patients completed the trial; 28 received compressed air massage. There was no difference in the mean age, Wagner score, ulcer size, pulse status, or peripheral sensation in the two groups. The time to healing in the compressed air massage group was significantly reduced: 58.1 +/- 22.3 days (95% confidence interval: 49.5-66.6) versus 82.7 +/- 30.7 days (95% confidence interval: 70.0-94.3) (P = 0.001). No adverse effects in response to compressed air massage were noted.

CONCLUSIONS

The addition of compressed air massage to standard medical and surgical management of diabetic ulcers appears to enhance ulcer healing. Further studies with this new treatment modality are warranted.

Management and prevention of diabetic foot ulcers and infections: a health economic review

Diabetic foot ulcers and infections are common and incur substantial economic burden for society, patients and families. We performed a comprehensive review, on a number of databases, of health economic evaluations of a variety of different prevention, diagnostic and treatment strategies in the area of diabetic foot ulcers and infections. We included English-language, peer-reviewed, cost-effectiveness, cost-minimization, cost-utility and cost-benefit studies that evaluated a treatment modality against placebo or comparator (i.e. drug, standard of care), regardless of year. Differences were settled through consensus. The search resulted in 1885 potential citations, of which 20 studies were retained for analysis (3 cost minimization, 13 cost effectiveness and 4 cost utility). Quality scores of studies ranged from 70.8% (fair) to 87.5% (good); mean = 78.4% +/- 5.33%.In diagnosing osteomyelitis in patients with diabetic foot infection, magnetic resonance imaging (MRI) showed 82% sensitivity and 80% specificity. MRI cost less than 3-phase bone scanning + Indium (In)-111/Gallium (Ga)-67; however, when compared with prolonged antibacterials, MRI cost $US120 (year 1993 value) more without additional quality-adjusted life-expectancy. Prevention strategies improved life expectancy and QALYs and reduced foot ulcer rates and amputations.Ampicillin/sulbactam and imipenem/cilastatin were both 80% successful in treating diabetic foot infections but the latter cost $US2924 more (year 1994 value). Linezolid cure rates were higher (97.7%) than vancomycin (86.0%) and cost $US873 less (year 2004 value). Ertapenem costs were significantly lower than piperacillin/tazobactam ($US356 vs $US503, respectively; year 2005 values). Becaplermin plus good wound care may be cost effective in specific populations. Bioengineered living-skin equivalents increased ulcer-free months and ulcers healed, but costs varied between countries. Promogran produced more ulcer-free months than wound care alone (3.75 vs 3.41 months, respectively). Treatment with cadexomer iodine resulted in higher rates of healed ulcer (29% vs 11%) and lower weekly treatment costs (Swedish krona [SEK]903 vs SEK1421; year 1993 values) than standard care. Filgrastim decreased hospital stays, time to resolution and costs (36% lower) compared with usual care. Adjunctive hyperbaric oxygen produced an incremental cost per QALY at year 1 of $US27 310 and $US2255 at year 12 (year 2001 values).Overall, preventive strategies were shown to be cost effective and potentially cost saving. Various antibacterial regimens are cost effective but empiric choices should be based on local resistance patterns. MRI was cost effective compared with three-phase bone scanning + In-111/Ga-67 but not against prolonged antibacterial therapy. Other innovations (becaplermin, bioengineered living-skin equivalents, filgrastim, cadexomer iodine ointment, hyperbaric oxygen, Promogran may be cost effective in this population but more studies are needed to confirm these findings.

Clinical and microbiological efficacy of colistin therapy in combination with rifampin and imipenem in multidrug-resistant Pseudomonas aeruginosa diabetic foot infection with osteomyelitis

The evaluation of the safety and effectiveness of colistin in association with rifampin and imipenem in 1 diabetic patient with severe diabetic foot infection (DFI) due to multidrug-resistant (MDR) Pseudomonas aeruginosa, complicated by osteomyelitis, is presented in this "Case Report". The patient received colistin after other ineffective antimicrobial treatment when an MDR P aeruginosa strain was isolated by cultural examination, together with a multidisciplinary care approach including surgical debridement and adequate offloading. The efficacy of combination colistin plus rifampin plus imipenem was observed with a checkerboard method and bactericidal activity of the serum. The patient received colistin combination therapy for 6 weeks with cure of the infection and without renal toxicity. These data suggest that colistin, in combination with rifampin and imipenem, is safe and effective, in promoting healing in DFI due to MDR P aeruginosa and suggest the need for controlled clinical studies.

Diabetic foot ulcers in Cameroon: can microflora prevalence inform probabilistic antibiotic treatment?

OBJECTIVE

To determine the clinical features, regularly associated microorganisms and their susceptibility to antibiotics, and the clinical outcomes of foot ulcers in patients with diabetes at the Yaoundé Central Hospital, Cameroon.

METHOD

A retrospective analysis of routinely collected hospital data, and data validation by survey of clinical notes was conducted from November 1999 to October 2002 for adult diabetic patients with foot ulcers. Clinical data were recorded for each patient, followed by a record of microbiological investigations where available.

RESULTS

Of 503 patients with diabetes admitted during the study period, 54 (10.7%) had foot ulcers. Male subject represented 66.7% of this population. The mean age of the study population was 59.66 +/- 1.52 years. The foot ulcer led to the diagnosis of diabetes in six patients in whom the condition was previously unidentified. Of the 54 patients with foot ulcers, nine (16.7%) were selected for surgery and the remaining 45 were managed conservatively. Microbiological investigations were available for 21 patients. Proteus mirabilis was the most frequent microorganism yielded, and was regularly associated with Staphylococcus aureus. All the microorganisms isolated showed high sensitivity to second-generation quinolone antibiotics and were regularly sensitive to aminoglycoside antibiotics. Nine (16.7%) patients died and seven (13%) were discharged at their own request.

CONCLUSION

The mortality rate among our diabetic patients with foot ulcers is high and the combination of second-generation quinolone and aminoglycoside antibiotics can be proposed as a probabilistic antibiotic approach to treating foot infection.

Evidence-Based Protocol for Diabetic Foot Ulcers

BACKGROUND

Diabetic foot ulcers are the single biggest risk factor for nontraumatic foot amputations in persons with diabetes. Foot ulcers occur in 12 to 25 percent of persons with diabetes and precede 84 percent of all nontraumatic amputations in this growing population. Because of the high incidence of foot ulcers, amputations remain a source of morbidity and mortality in persons with diabetes. Strict adherence to evidence-based protocols as described herein will prevent the majority of these amputations.

METHODS

The collective experience of treating patients with neuropathic diabetic foot ulcers in four major diabetic foot programs in the United States and Europe was analyzed.

RESULTS

The following protocol was developed for patients with diabetic foot ulcers: (1) establishment of good communication among the patient, the wound healing team, and the primary medical doctor; (2) comprehensive, protocol-driven care of the entire patient, including hemoglobin A1c, microalbuminuria, and cholesterol as well as early treatment of retinopathy, nephropathy, and cardiac disease; (3) weekly objective measurement of the wound with digital photography, planimetry, and documentation of the wound-healing process using the Wound Electronic Medical Record, if available; (4) objective evaluation of blood flow in the lower extremities (e.g., noninvasive flow studies); (5) débridement of hyperkeratotic, infected, and nonviable tissue; (6) use of systemic antibiotics for deep infection, drainage, and cellulitis; (7) off-loading; (8) maintenance of a moist wound bed; (9) use of growth factor and/or cellular therapy if the wound is not healing after 3 weeks with this protocol; and (10) consideration of the use of vacuum-assisted therapy in complex wounds.

CONCLUSIONS

In diabetic foot ulcers, availability of the above modalities, in combination with early recognition and comprehensive treatment, ensures rapid healing, minimizes morbidity and mortality rates, and eliminates toe and limb amputations in the absence of ischemia and osteomyelitis.

Etiology of insulin resistance

Type 2 diabetes mellitus is a major cause of morbidity and mortality worldwide, and the prevalence is set to increase dramatically over the coming decades. Understanding the metabolic pathways that lead to type 2 diabetes is therefore an important healthcare objective. Novel investigational techniques based on magnetic resonance spectroscopy (MRS) have allowed real-time insight into the molecular defects in patients with type 2 diabetes, revealing that insulin resistance is a product of decreased insulin-stimulated skeletal muscle glycogen synthesis, which can mostly be attributed to decreased insulin-stimulated glucose transport (Glut 4) activity. This defect appears to be a result of intracellular lipid-induced inhibition of insulin-stimulated insulin-receptor substrate (IRS)-1 tyrosine phosphorylation resulting in reduced IRS-1-associated phosphatidyl inositol 3 kinase activity. The hypothesis that insulin resistance is a result of accumulation of intracellular lipid metabolites (e.g., fatty acyl CoAs, diacylglycerol) in skeletal muscle and hepatocytes is supported by observations in patients and mouse models of lipodystrophy. Furthermore, the increase in hepatic insulin sensitivity observed in patients with type 2 diabetes following weight loss is also accompanied by a significant reduction in intrahepatic fat without any changes in circulating adipocytokines (interleukin-6, resistin, leptin). Finally, recent MRS studies in healthy, lean, elderly subjects and lean insulin-resistant offspring of parents with type 2 diabetes have demonstrated that reduced mitochondrial activity may also lead to increased intramyocellular lipid content and insulin resistance in skeletal muscle in these individuals. In summary, in vivo MRS has proved to be an important tool for elucidating the causal chain of events that causes insulin resistance. Understanding the cellular mechanism(s) of insulin resistance in turn offers the prospect of better targeted and more effective therapeutic interventions for treatment and prevention of type 2 diabetes.

Quality of life of adults with unhealed and healed diabetic foot ulcers

BACKGROUND

Diabetic foot ulcers cause major treatment morbidity and cost of care. This study evaluated quality of life in patients with unhealed and healed diabetic foot ulcers.

METHODS

This was a cross-sectional study of adult diabetic patients (age 45 years or older) treated in a tertiary care foot clinic who had foot ulcers within the preceding 2 years. Patients with other diabetic complications or conditions that would potentially affect quality of life were excluded. Two patient groups of comparable age, gender distribution, and duration of diabetes were studied: 57 patients with unhealed ulcers (minimum duration, 6 months) and 47 patients with healed ulcers. Telephone interviews were done using the Short Form 12 (SF-12) (both groups) and a Cardiff Wound Impact Scale (CWIS) (unhealed ulcer group).

RESULTS

The mean SF-12 Physical Component Summary score was significantly lower for the group with unhealed ulcers (unhealed, 35 +/- 8 points; healed, 39 +/- 10 points; p = 0.04); these scores for both groups were significantly lower than published Short Form 36 (SF-36) scores for general, diabetic, and hypertensive populations. The mean SF-12 Mental Component Summary scores of the groups did not differ significantly from each other or from published population scores. CWIS responses showed that patients with unhealed ulcers were frustrated with healing and had anxiety about the wounds, resulting in marked negative impact on the average Well-being Component Score (35 +/- 6 points).

CONCLUSIONS

Individuals with diabetic foot ulcers experience profound compromise of physical quality of life, which is worse in those with unhealed ulcers.

Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial

BACKGROUND

Diabetic foot wounds, particularly those secondary to amputation, are very complex and difficult to treat. We investigated whether negative pressure wound therapy (NPWT) improves the proportion and rate of wound healing after partial foot amputation in patients with diabetes.

METHODS

We enrolled 162 patients into a 16-week, 18-centre, randomised clinical trial in the USA. Inclusion criteria consisted of partial foot amputation wounds up to the transmetatarsal level and evidence of adequate perfusion. Patients who were randomly assigned to NPWT (n=77) received treatment with dressing changes every 48 h. Control patients (n=85) received standard moist wound care according to consensus guidelines. NPWT was delivered through the Vacuum Assisted Closure (VAC) Therapy System. Wounds were treated until healing or completion of the 112-day period of active treatment. Analysis was by intention to treat. This study has been registered with , number NCT00224796.

FINDINGS

More patients healed in the NPWT group than in the control group (43 [56%] vs 33 [39%], p=0.040). The rate of wound healing, based on the time to complete closure, was faster in the NPWT group than in controls (p=0.005). The rate of granulation tissue formation, based on the time to 76-100% formation in the wound bed, was faster in the NPWT group than in controls (p=0.002). The frequency and severity of adverse events (of which the most common was wound infection) were similar in both treatment groups.

INTERPRETATION

NPWT delivered by the VAC Therapy System seems to be a safe and effective treatment for complex diabetic foot wounds, and could lead to a higher proportion of healed wounds, faster healing rates, and potentially fewer re-amputations than standard care.

The prevention of diabetic microvascular complications of diabetes: is there a role for lipid lowering?

The role of hyperglycemia in the development of microvascular complications of diabetes, such as nephropathy, retinopathy and neuropathy, has been well documented. Evidence is accumulating to support the concept that dyslipidemia can also contribute to the development of these complications. Lipid-lowering agents, such as statins, have been shown to prevent cardiovascular events in patients with diabetes. However, in addition to preventing macrovascular diseases, statins may also be able to retard the progression of microvascular complications of diabetes. Indeed, in addition to reducing lipid levels, these agents can improve endothelial function and reduce oxidative stress, which can improve microvascular function. These findings would provide further support for the use of lipid-lowering agents in patients with diabetes.